白血病患者造血干细胞移植前单次全身照射的预后分析

目的 回顾性分析单次全身照射(SFTBI)后行造血干细胞移植的白血病患者的预后及相关因素.方法 2008 年9月前7年半余共102例患者行SFrBI后移植.比较不同病理类型、移植方式及不同TBI参数组间生存率、复发率及间质性肺炎(IP)发生率差异,分析生存率、复发率和IP发生率的相关因素.结果 随访15～1482 d(中位值406 d).随访率为95.1%,随访满1、3年者分别为86、55例.1、3年生存率分别为59.0%、44.0%,单因素分析3年生存率有差异因素包括移植前有无复发(20%:55%,χ2=6.33,P=0.012)、移植方式(异基因比自体基因移植,39%:68%,χ2=8.06,P=0.005)、急性移植物抗宿主病(aGVHD)级别(≥3级比0～2级,0%:54%,χ2=7.52,P=0.006)、移植后有无复发(19%:58%,χ2=10.13,P=0.001)、有无IP(23%:58%,χ2=8.35,P=0.004).Cox模型多因素分析对生存有影响因素只有≥3级aGVHD(χ2=12.74,P=0.000).1、3年复发率分别为30.0%、50.0%,移植前已有过复发比无复发的复发率明显升高(47%:16%,χ2=7.32,P=0.007),Cox模型多因素分析显示移植前已有过复发对术后复发有影响(χ2=9.39,P=0.020).IP发生率为35.0%,全身剂量均匀度>3%和≤3%的分别为27%和4%(χ2=5.21,P=0.023),急性腮腺炎有和无的分别为34%和3%(χ2=14.15,P=0.000),异基因移植和自体移植的分别为31%和8%(χ2=7.70,P=0.006).Logistic多因素分析显示移植方式、急性腮腺炎及全身剂量均匀度对IP发生有影响(χ2=10.08、10.08、7.69,P=0.002、0.002、0.010).结论 ≥3级aGVHD患者3年生存率明显下降,全身剂量均匀性对IP发生有重要意义,异基因移植者更易发生IP,急性腮腺炎与IP明显相关,可能对预测IP发生有一定价值.     

白血病患者造血干细胞移植前单次全身照射的预后分析

Objective To analyze the prognostic factors of patients with leukemia treated with single fraction total body irradiation (SFTBI) followed by hernatopoietic stem cell transplantation (HSCT).Methods From January 2001 to September 2008, 102 patients received HSCT. The differences of the survival rate, relapse rate and incidence of interstitial pneumonia (IP) between groups regarding different genders, ages, pathological types, transplantation methods and TBI parameters were compared and the factors related with the survival rate, relapse rate and incidence of IP were analyzed. Results The followup time ranged from 15 to 1482 days (median, 406 days). The follow-up rate was 95.1%. 86 and 55patients were followed up more than one year and three years. The 1-and 3-year survival rates were 59.0%and 44.0%. In univariate analysis, the 3-year survival rate was signifcantly different between the groups with and without relapse before transplantation (20% vs. 55%, χ2 = 6.33, P = 0. 012), allogeneictranplantation versus autologous tranplantation (39% vs. 68%, χ2 = 8.06, P = 0.005), grade 3 or more acute graft versus host disease (aGVHD) and grade 0 -2 aGVHD (0% vs. 54%, χ2 = 7.52, P = 0.006),with and without relapse after transplantation (19% vs. 58%, χ2 = 10.13, P =0.001), with and without IP (23% vs. 58%, χ2 =8.35, P=0.004). Multivariate analysis showed that grade 3 or more aGVHD was the only statistically significant prognostic factors (χ2 = 12. 74 ,P =0. 000). The l-and 3-year relapse rateswere 30. 0% and 50. 0%. The incidence of relapse was obviously higher in the group with relapse before transplantation than that without (47% vs. 16%, χ2 =7. 32, P=0. 007). Multivariate analysis showed thatrelapse before transplantation was a significant factor predicting relapse after transplantation (χ2 = 9. 39,P =0. 020). The cumulative incidence of IP was 35.0%. The incidence of IP was different between groups with dose homogeneity > 3% and ≤ 3% (27% vs. 4%, χ2 = 5. 21, P = 0. 023), with and without acute parotitis (34% vs. 3%, χ2 = 14. 15, P= 0.000), allogeneic transplantation group and autologous transplantation group (31% vs. 8%, χ2= 7.70, P= 0.006). Multivariate analysis showed that transplantation methods, acute parotitis and dose homogeneity were statistically significant factors in predictingIP (χ2 = 10. 08 , 10. 08 and 7.69 , P = 0. 002 , 0. 002 and 0. 010 , respectively) . Conclusions Patients who develop grade 3 or higher aGVHD have poor prognosis. Dose homogeneity influences the incidence of IP. Patients undergoing allogeneic transplantation are apt to have IP. Acute parotitis is related with IP and might be a predictor.     

急性白血病造血干细胞移植前单次全身照射与分次全身照射模式的对比分析

目的对比单次全身照射(single total body irradiation,STBI)8Gy和分次全身照射(fractionated total body irradiation,FTBI)12Gy两种不同的全身照射模式,探讨合适的造血干细胞移植前全身照射(total body irradiation,TBI)方案。方法回顾性分析苏州大学附属第一医院2003-04-05-2010-07-10确诊的160例急性白血病患者资料,所有患者均接受移植前TBI预处理,70例患者进行STBI 8Gy照射,90例患者行FTBI 12Gy照射,2次/d,2Gy/次,连续照射3d,2次间隔6h,比较不同方案的急性期毒副作用、造血重建时间、移植存活率、间质性肺炎(interstitial pneumonia,IP)和急性移植物抗宿主病(acute graft-versus host disease,aGVHD)的发生情况。结果 STBI 8Gy照射组和FTBI 12Gy照射组胃肠道反应(恶心、呕吐)发生率分别为61.4%(43/70)和40.0%(36/90),χ2=7.223,P=0.006;口腔黏膜炎分别为71.4%(50/70)和45.6%(41/90),χ2=10.746,P=0.001;腮腺炎分别为64.3%(45/70)和48.9%(44/90),χ2=3.782,P=0.037。两组上述毒副作用相比差异有统计学意义。STBI 8Gy组中性粒细胞造血重建时间、血小板造血重建时间、移植存活率和Ⅲ~Ⅳ度aGVHD的发生率分别为13.84±3.84、16.69±4.70、95.7%(67/70)和14.3%(10/70),FTBI12Gy组分别为14.31±3.79、17.43±5.26、95.6%(86/90)和16.7%(15/90),两组相比差异无统计学意义。IP发生率FTBI 12Gy照射组为4.4%(4/90),STBI 8Gy照射组为14.3%(10/70)。多因素Logistic回归分析显示,IP的发生与照射方案和剂量率有关,与性别、年龄、干细胞来源和腮腺炎无关。结论 FTBI 12Gy方案与STBI 8Gy方案相比可减轻急性期毒副作用,减轻肺部放射损伤,而造血重建时间、移植存活率和aGVHD的发生两种方案相比差异无统计学意义。采用FTBI 12Gy方案,吸收剂量率控制在4~6cGy/min,肺中位剂量控制在<8Gy,对比STBI 8Gy方案是安全、有效的造血干细胞移植预处理方案。     

含全身照射方案的造血干细胞移植对难治性白血病的疗效

目的探讨含全身照射(TBI)预处理方案的造血干细胞移植(allo-HSCT)对难治性白血病的疗效和安全性。方法采用含TBI预处理方案的allo-HSCT治疗20例难治性白血病患者,采用骨髓加外周血干细胞联合移植,预处理方案包括阿糖胞苷、氟达拉滨及TBI等,全身照射采用6MV-X照射,移植物抗宿主病(GVHD)预防采用经典环孢菌素A(CSA)和氨甲蝶呤(MTX)及抗胸腺细胞免疫球蛋白(ATG)、CD25单克隆抗体,移植后观察并发症和患者无病生存等情况。结果 20例患者均获造血重建,植入证据检测证实100%为完全供者造血。TBI后患者有轻度恶心、呕吐、腮腺肿胀等症状,无1例发生间质性肺炎。中位随访时间为12.5个月(6～36个月),共8例发生GVHD,死亡2例;因感染死亡2例、复发死亡6例,其余10例患者仍无病生存,2年无病生存率为50%。结论含全身照射方案的造血干细胞移植,对难治性白血病是1种安全有效的治疗方案,可作为挽救治疗的关键技术。广泛应用于临床。     

造血干细胞移植患者术前全身照射的摆位体会

目的：总结全身照射摆位作业流程的体会,促进和提高全身照射的技术水平。方法：明确全身照射工作流程,抓住重点,细致规划。预先调试治疗设备、治疗床和肺挡块的位置,治疗时仅予以微调,及时与患者保持必要的沟通,保证体位的稳定舒适。结果：通过优化工作流程,工作效率明显提高,整个治疗过程时间缩短,患者的体位稳定性和耐受性都得到了提高。结论：充分细致的准备工作,熟练的摆位技术对提高治疗准确性和患者的可耐受性有重要价值。     

造血干细胞移植前全身照射急性放射性反应与照射剂量的关系

目的探讨造血干细胞移植前全身照射急性放射性反应与照射不同总剂量及分次剂量的关系。方法回顾性分析2015年5月至2019年12月于石家庄平安医院造血干细胞移植前接受6 MV X线全身照射预处理的48例患者的临床资料。将患者按照射总剂量分为8 Gy组(12例)、10 Gy组(31例)和12 Gy组(5例),按分次照射剂量分为4 Gy/次组(17例)和5 Gy/次组(31例),总结比较各组患者放疗后的口腔黏膜、咽部、涎腺、上消化道、下消化道及肺的急性放射性反应发生情况。结果照射总剂量8 Gy组咽部急性放射性反应0级11例(91.7%),1级1例(8.3%);10 Gy组0级10例(32.3%),1级13例(41.9%),2级4例(12.9%),3级3例(9.7%),4级1例(3.2%);12 Gy组0级2例(40.0%),1级、2级、3级各1例(20.0%);照射总剂量8 Gy组咽部急性放射性反应较10 Gy组和12 Gy组轻,差异有统计学意义(χ2=11.338,P=0.003);其他部位急性放射性反应发生率差异均无统计学意义(均P>0.05)。分次照射剂量4 Gy/次组咽部急性放射性反应0级13例(76.5%),1级2例(11.8%),2级、3级各1例(5.9%);5 Gy/次组0级10例(32.3%),1级13例(41.9%),2级4例(12.9%),3级3例(9.7%),4级1例(3.2%);分次照射剂量4 Gy/次组咽部急性放射性反应较5 Gy/次组轻,差异有统计学意义(Z=-2.606,P=0.009);其他部位急性放射性反应发生率差异均无统计学意义(均P>0.05)。结论造血干细胞移植前全身照射总剂量8 Gy及分次剂量4 Gy/次能减轻咽部急性放射性反应。     

造血干细胞移植前全身照射的毒副反应及影响因素分析

目的　观察和分析造血干细胞移植前采用全身照射治疗所产生的近期和晚期毒副反应。方法　自１９９９年５月至２００５年１２月,我科对３１２例造血干细胞移植患者进行了全身照射。采用６０Ｃｏγ射线照射,患者取侧卧体位,腹脐处中心平面剂量率控制在４～６ｃＧｙ／ｍｉｎ,平均（５.２±１.１３）ｃＧｙ／ｍｉｎ,总剂量７～１２Ｇｙ,分１～３次照射,每天照射１次,照射期间制作个体化的肺挡铅进行肺屏蔽。结果　在全身照射后,患者近期出现了Ⅰ ～Ⅱ级的发热、胃肠道反应、口腔炎及出血性膀胱炎,均可耐受,无需特殊处理。间质性肺炎发生率为９.９％,造血系统重建和干细胞植活率达７０％以上,患者均未出现严重的肾功能衰竭。结论　采用剂量率５ｃＧｙ／ｍｉｎ照射,总照射剂量控制在７～１２Ｇｙ,肺中位剂量不超过７.５Ｇｙ,１次／天,共照射１～３次的剂量分割模式,是有效和安全的造血干细胞移植预处理方案。     

优化全身照射技术对造血干细胞移植后发生间质性肺炎影响的初步观察

目的:探讨优化医用直线加速器高能X线全身照射(total body irradiation, TBI)的技术对造血干细胞移植后发生间质性肺炎(IP)的影响.方法:28例患者接受以环磷酰胺(CY) 全身放疗±依托泊苷(Vp-16)为预处理方案的造血干细胞移植,TBI采用分割放疗、肺挡铅技术,其中19例患者采用热释光剂量片(TLD)监测全身放疗的肺吸收剂量,TBI总量12Gy,共6次,肺部剂量8.5Gy.结果:28例患者随访24～104个月,中位随访时间75个月,5年总生存率(OS)为(53.6±9.4)%,5年无复发生存(RFS)(71.1±8.6)%;19例接受热释光剂量片监测吸收剂量的患者,肺吸收中位剂量8.44Gy,脐部吸收中住剂量11.87Gy,全身剂量的不均匀性<±10%;28例患者无1例发生IP.结论:采用分割全身放疗、肺挡铅、并用热释光剂量片监测肺吸收剂量可降低IP的发生.     

Study on fractionated total body irradiation before hematopoietic stem cell transplantation

OBJECTIVE To observe the dose and the complications from total body irradiation before hematopoietic stem cell transplantation. METHODS This study involved 312 patients with total body irradiation before hematopoietic stem cell transplantation. They were entered into the treated research from May 1999 to October 2005. All patients had received the irradiation from ^60Co of an absorbed dose rate of （5.2 ± 1.13） cGy/min. The total dose of TBI was 7-12 Gy, 1 f/d × 2 d. A high-dose rate group （〉 10 Gy） included 139 cases and a low-dose rate group （〈 10 Gy） included 173 cases. RESULTS The probability of acute gastrointestinal reactions in the high-dose rate group was more compared with that in the low-dose rate group. The differences for other reactions, such as hematopoietic reconstitution and graft survival rate, between the two groups were insignificant. CONCLUSION Using fractional total body irradiation at a dose rate of 5 cGy/min, with a total dose of 7-12 Gy, 1 f/d × 2 d, with the lung receiving under 7.5 Gy is a safe and effective pretreatment for hematopoietic stem cell transplantation.     

异基因造血干细胞移植治疗恶性血液病的预后分析

Objective To explore the clinical related prognostic factors of allogeneic hematopoietic stem cell transplantation (allo-HSCT) in treating malignant hematological diseases. Methods From September 1997 to August 2008,a total of 26 patients with hematological diseases were treated with allo-HSCT from HLA identical-sibling and haplo-identical donors in our hospital, including 14 patients with acute leukemias,10 with chronic myeloid leukemias,and 2 myelodysplastic syndromes. Results All patients achieved sustained full donor type engraftment. The cumulative overall survival (OS) was 63.9 %,and cumulative disease free survival (DFS) was 62.6 %. Fifteen patients had graft-versus-host disease (GVHD) (57.7 %),including 8 acute GVHD(aGVHD) (30.8 %) (grade Ⅲ-Ⅳ aGVHD was 15.4 %) and 7 chronic GVHD. GVHD between HLA identical-sibling and haplo-identical donors was different and there was statistic difference between the two groups (P=0.014). 4 patients relapsed,7 patients died. The univariate analysis showed OS were correlated with grade Ⅳ aGVHD (P=0.05) and CMV infection (P=0.027). Conclusion Allo-HSCT is effective for the cure of patients with malignant hematological diseases. The key to improve the efficacy of HSCT is to reduce the incidence of transplant-related complications,especially GVHD and infection.     

异基因造血干细胞移植治疗恶性血液病的预后分析

Objective To explore the clinical related prognostic factors of allogeneic hematopoietic stem cell transplantation (allo-HSCT) in treating malignant hematological diseases. Methods From September 1997 to August 2008,a total of 26 patients with hematological diseases were treated with allo-HSCT from HLA identical-sibling and haplo-identical donors in our hospital, including 14 patients with acute leukemias,10 with chronic myeloid leukemias,and 2 myelodysplastic syndromes. Results All patients achieved sustained full donor type engraftment. The cumulative overall survival (OS) was 63.9 %,and cumulative disease free survival (DFS) was 62.6 %. Fifteen patients had graft-versus-host disease (GVHD) (57.7 %),including 8 acute GVHD(aGVHD) (30.8 %) (grade Ⅲ-Ⅳ aGVHD was 15.4 %) and 7 chronic GVHD. GVHD between HLA identical-sibling and haplo-identical donors was different and there was statistic difference between the two groups (P=0.014). 4 patients relapsed,7 patients died. The univariate analysis showed OS were correlated with grade Ⅳ aGVHD (P=0.05) and CMV infection (P=0.027). Conclusion Allo-HSCT is effective for the cure of patients with malignant hematological diseases. The key to improve the efficacy of HSCT is to reduce the incidence of transplant-related complications,especially GVHD and infection.     

异基因造血干细胞移植治疗恶性血液病的预后分析

 目的　探讨异基因造血干细胞移植（allo-HSCT）治疗恶性血液病的预后相关因素。方法　1997年7月至2008年8月,对26例血液病患者行allo-HSCT,其中急性白血病（AL）14例,慢性髓系白血病（CML）10例,骨髓增生异常综合征（MDS）2例;移植供受体22例为同胞HLA全相合,4例为同胞HLA不全相合。结果　所有患者达到稳定的供者植入,随访至今,累积总生存（OS）率为63.9 %,累积无病生存（DFS）率为62.6 %;15例（57.7 %）发生移植物抗宿主病（GVHD）,其中急性GVHD 8例（30.8 %）[Ⅲ～Ⅳ度4例（15.4 %）],慢性GVHD 7例;HLA全相合与 HLA不全相合移植间GVHD发生率差异有统计学意义（P＝0.014）;复发4例;死亡7例。单因素分析结果显示,发生Ⅳ度GVHD、巨细胞病毒（CMV）感染是影响患者生存的高危因素,组间比较差异有统计学意义（P＝0.05和P＝0.027）。结论　allo-HSCT是目前治疗恶性血液病的有效方法,提高allo-HSCT疗效的关键是控制移植相关并发症,特别是GVHD和感染。     

异基因造血干细胞移植治疗白血病的临床研究

目的探讨异基因造血干细胞移植治疗白血病。方法脐血移植治疗儿童白血病3例,异基因外周血造血干细胞移植治疗白血病3例。结果6例患者完全植入,+15～+25天白细胞(WBC)>1.0×109/L,+35天～+51天血小板(Plt)>20×109/L。例1出现急性GVHDⅠ度,例5出现急性GVHDⅣ度,例6出现肝静脉闭塞综合征(VOD)、急性GVHDⅠ度、出血性膀胱炎(HC),例2移植后6个月复发,放弃治疗死亡。余5例正常生活或工作。结论异基因造血干细胞移植治疗白血病是安全有效的方法。